Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has served on the AMA-CPT Advisory Committee.

Dirk M. Elston, MD, addresses important coding and documentation questions each month in Cracking the Code. Dr. Elston, who serves as director of the Ackerman Academy of Dermatopathology in New York, has represented the American Academy of Dermatology on the AMA-CPT Advisory Committee.

By Dirk Elston, MD, May 01, 2012

I just read a scar revision specimen (repair of a traumatic scar) and coded it as 88305. Is this correct?

Surgical pathology codes (88300-88309) are used to report gross and microscopic examination of surgical specimens. The codes include accessioning, examination, and reporting, so those services would not be reported separately. The codes listed above do not include frozen sections, special stains, or immunostains, so those are coded in addition when provided.

The unit of service for codes 88300 through 88309 is the specimen, defined as tissue submitted by the surgeon for individual and separate attention, requiring individual examination and pathologic diagnosis. In general, each bottle of formalin will contain a separate specimen, and each will be given a part designation, such as A, B, or C, under an accession number that includes all specimens received on that patient on a single date of service. For example: Three moles removed from a patient on a single day become specimens S12-1111 parts A, B, and C. Each of these parts will need to be handled and read separately, and each will result in a unit of service assigned an individual code reflective of the proper level of service.[pagebreak]

88300

Code 88300 is used for specimens that can be accurately diagnosed without microscopic examination (gross examination only). This may include specimens such as avulsed nails, cyst contents, and foreign bodies, when approved for gross examination only by the hospital tissue committee.

88302

Code 88302 is used when the tissue is expected to be normal. Gross and microscopic examination is performed to confirm that tissue was obtained and to confirm the absence of disease. It would be used for specimens such as fingers or toes removed by traumatic amputation, normal newborn foreskin, or plastic repair.

88304 - 88309

Service codes 88304 through 88309 describe increasing levels of physician work required for all other specimens requiring gross and microscopic examination (except for frozen sections and Mohs specimens, described below).

88304

Code 88304 includes gross and microscopic examination of a cyst, tag, or lipoma, but also includes gross and microscopic examination of an abscess, cholesteatoma, conjunctival biopsy, Dupuytren’s contracture, fissure or fistula, foreskin other than newborn, hematoma, mucocele, pilonidal sinus, debridement, or varicosity.

88305

Code 88305 is used for all other skin specimens, as well as temporal artery biopsy, oral mucosal biopsies, lymph node biopsy, and muscle, soft tissue, nerve, or salivary gland biopsies. This code as well as other pathology codes that might be reported by a dermatologist will be discussed next month.[pagebreak]

Mohs exception

These codes should not be reported on the same specimen as part of Mohs surgery except in unusual circumstances when a Mohs specimen needs subsequent special evaluation. The official AAD position statement on appropriate uses of paraffin sections in association with Mohs micrographic surgery lists the following as examples that may justify appropriate use of a second opinion from a pathologist:

(1) A second opinion consultation is required during surgical treatment of melanoma;

(2) Further tissue processing is required to assess features of an aggressive, deep, or histologically unusual tumor;

(3) Paraffin section evaluation is used to confirm a diagnosis other than what was found on a prior pathology report, upon which Mohs surgery was done;

(4) Further tissue analysis is necessary to complete the staging of a tumor so that the need for additional therapy, such as radiation or chemotherapy, can be determined;

(5) Unusual findings during frozen section evaluation, or during other portions of the Mohs case, lead the physician to conclude that a second pathologic opinion is necessary;

(6) Despite proper processing technique, frozen section interpretation is not sufficient to assess the tissue margin with a high degree of reliability;

(7) A biopsy specimen of tumor not previously biopsied is obtained and assessed by frozen section immediately before commencement of Mohs; the pathologic diagnosis is then confirmed by paraffin section; or

(8) Special stains are required that are not done on frozen sections but are on paraffin sections.

As stated, the above is the AAD position statement and does not necessarily reflect the claim payer’s opinion. (The full position statement is available online at www.aad.org/Forms/Policies/ps.aspx.) To ensure that you are meeting the appropriate payer guidelines and requirements, one is encouraged to obtain and review payer coverage policy to ensure the appropriate guidelines are followed and avoid claim denials and/or audits at a later stage.

Example 1:

You receive an excision specimen for an irregular pigmented lesion. Microscopically, it represents an atypical nevus. You report your reading using the code 88305.

Correct: The proper code for gross and microscopic examination of most skin specimens, including pigmented lesions, is 88305.

Example 2:

You receive an excision of a mass on the mucosal lower lip. Microscopic examination reveals a mucocele. You report 88305.

Incorrect: The proper code for gross and microscopic examination of a mucocele is 88304.

Example 3:

You receive a circumcision specimen from a 65-year-old diabetic man. You report your reading using the code 88305.

Incorrect: The proper code for gross and microscopic examination of foreskin, other than newborn, is 88304.